March 2006

A Two-Part Success Formula

By Sue Golden, PT

Cutting-edge technologies enhance results of gait and balance evaluation and training.

Partial weight bearing gait and balance therapy systems help improve strength, balance, and lower extremity coordination.

For patients to improve their physical condition with gait and balance training, their therapy program requires two essential elements: An institutional commitment to harnessing the latest in technological developments, and a dedicated and engaged clinical team, including physical therapists. Good Shepherd Rehabilitation Network combines both in its comprehensive inpatient and outpatient services throughout eastern Pennsylvania. Among its core competencies is its neurorehabilitation program. Supported by 19 trained therapists in the four categories of occupational, physical, psychological, and speech, Good Shepherd’s neurorehab program has a proven record of success in returning patients to healthier and more active lives.

TECHNIQUES AND DEVICES

Good Shepherd’s physical therapists use a wide range of techniques and rehabilitative technology when working with patients. Before gait and balance training begins, an individual patient evaluation is obtained. This becomes the foundation for a comprehensive and individualized training program. The stepping stone from evaluation to initial training starts with a computerized balance technology device that provides objective assessment and retraining of the sensory and voluntary motor control of balance. In concert with a physical therapist, patients generally use this device to determine the location of their center of gravity; physical therapists use the device to acquire a baseline for ongoing therapy for each patient. The device provides visual biofeedback for patients, as well as objective data through graphs and numbers, enabling them to understand their condition.

A special walker is used to “un-weigh” a patient, facilitating lower extremity movement.

The computerized balance technology provides individual results. By quantifying each patient’s deficits, a physical therapist determines the best therapy program for that patient. Crucial to a patient’s rehabilitation process, the individual therapy programs illustrate how precise and effective computerized balance technology is for each patient.

In addition to assisting with the evaluation process, computerized balance technology is also a useful tool for treatment and training. Patients use it to learn how to shift their weight and build strength. Its primary use is to adapt, develop, and integrate a patient’s sensory systems into their balance reactions.

An additional highlight of computerized balance technology is its appeal to a wide range of patient diagnoses and ages. Those suffering and recovering from stroke, spinal cord injury, head injuries, back pain, vertigo, pediatric developmentally delayed condition, limb amputation, and neuromuscular diseases are capable of using this machine.

Many Good Shepherd patients have benefited from a comprehensive rehabilitation effort that includes computerized balance technology. One in particular, a senior citizen recovering from a stroke, complained of unsteadiness. As part of the comprehensive approach to her care, occupational therapists assessed her capabilities in Good Shepherd’s kitchen to re-create a similar setting at home where she was originally having these problems. They watched her ability in performing activities of daily living skills and found that she was unsteady.

Once she was placed on the computerized balance technology unit, the physical therapist conducted a sensory organization test, which measures a patient’s sway against age-normative data (a patient’s balance compared to that of a person of the same age). After testing her somatosensory, visual, and vestibular systems, the results showed that she had vestibular problems. While on the computerized balance technology unit, the patient had trouble keeping her balance with her eyes closed on a mobile surface. The physical therapist used this information to guide her treatment and determine what functional activities she may have difficulty with at home, such as waking up in the middle of the night and walking to the bathroom. After repeated treatments on the computerized balance technology unit over a month-long period and receiving an at-home exercise program, the patient left Good Shepherd with the confidence that she had overcome her unsteadiness. Repeated testing on the unit showed that the patient had improved, with normal vestibular function on the sensory organization test.

“It is a testament to our comprehensive approach to treatment that we were able to work together and identify all of the issues that mattered and provide therapy programs for her here and at home that enabled her to get her life back with confidence,” says Nathan Diffenbaugh, a physical therapist for Good Shepherd.

Another advancement for evaluating and training patients that Good Shepherd uses includes a computer equipped with virtual reality software, a digital camera, and a monitor. The camera projects the patient’s image on the monitor with a virtual background, such as a ski hill or a soccer field, and occupational settings, such as a factory.

More of a “hands-on” tool for patients, the digital virtual reality system is regarded as a valuable program by both physical therapists and patients because it places patients in more real life situations. With the factory background, for example, patients take boxes off a conveyor belt and place them elsewhere. This exercise enables patients to work on weight-shifting and moving out of their base of support. Diffenbaugh says, “The program is something that patients can enjoy while doing therapy. Being placed in more lifelike, everyday situations creates a comfort zone for patients.”

Good Shepherd’s neurorehab program provides several mobility devices that simply focus on training. One of the most basic and initially used pieces of equipment is a highly mobile true partial weight-bearing system. Therapists use this device to help “un-weight” patients to allow easier lower extremity movement. Patients are then capable of learning how to control pelvic movement and weight-shifting, and how to break down the components of walking with the system.

Two specialized body-weight support systems are another part of the Good Shepherd neurorehab program. These technologies are crucial for patients recovering from strokes, spinal cord injury, or head injuries, and in managing Parkinson’s disease and other neuromuscular diseases.

One system consists of a harness and an electrical lift, and can be used on either land or a treadmill. Patients learn how to pattern correct lower extremity movements, improving timing and lower extremity coordination. Physical therapists consider this equipment an excellent starting point for patients to build strength, balance, and the lower extremity coordination they need for gait.

The other system is an electronically controlled pneumatic body-weight support system that allows modulation and control of ground reaction forces. It quantifies body-weight support levels in real time throughout the step cycle. This device provides stability during gait and helps progress weight-bearing according to the patient’s needs. The system gives patients a real sense of falling without them actually doing so. Patients rely on physical therapists giving manual cues, and although this device is considered more labor intensive, the success rate is high.

“[These devices] have changed our view on balance and how important it is to function,” says Diffenbaugh. “We used to train very clinically, but now we look at the components more than we ever did before and see an overall improvement in patient response.”

Body weight support systems provide such benefits as lateral stability during step training and continuous computer-monitoring.

Of the devices Good Shepherd provides for gait and balance training, physical therapists regard the computerized balance technology unit and the

specialized body-weight support system with a harness and an electrical lift among the most valuable pieces for their patients.

The objective feedback given by computerized balance technology and the wide scope of patients who have access to these two devices assure the physical therapists’ confidence in their effectiveness. Diffenbaugh says, “Patients love to see themselves and how they move. Both of these support tools provide that for our patients.”

HOME EXERCISE PROGRAM

Patients’ individual evaluations not only determine the customized treatments they receive in the clinic, but also determine the content of their home exercise programs. Patients are given exercises to do independently at home starting as early as their initial visits to Good Shepherd. Patients may be given adaptation, balance, and strengthening exercises depending on their specific limitations. These programs are continually modified and progressed to challenge the patients as they improve.

THE ROLE OF A PHYSICAL THERAPIST

Technology alone cannot improve a patient’s gait and balance. It takes dedication and enthusiasm from physical therapists for patients to reach their fullest potential. A good physical therapist treats the injury; a great physical therapist treats the patient. At Good Shepherd, physical therapists take on the role of trainer, mentor, and friend. They learn to relate to the patients’ problems and feelings and build relationships that encourage the patients to reach their goals.

“In my work environment, we are our patient’s greatest advocates,” Diffenbaugh says. “Quite apart from the rigors of physical therapy, we become their biggest cheerleaders. Without the moral support, the commitment to their recovery, and the promise to provide the right rehabilitative programs for success, all the technology in the world won’t get a patient back where he or she wants to be.”

Good Shepherd’s comprehensive approach to therapy, commitment to employing a highly skilled staff, and the utilization of the latest rehabilitative technology and treatment methods result in positive outcomes for their patients.

Sue Golden, PT, is the outpatient regional manager of Good Shepherd Rehabilitation Network, Allenton, Pa.

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